A Multimodal Exertional Test for concussion: a pilot study in healthy athletes.

Introduction: Exertional tests have become a promising tool to assist clinicians in the management of concussions, however require expensive equipment, extensive spaces, and specialized clinician expertise. As such, we developed a test with minimal resource requirements encompassing key elements of sport and physical activity. The purpose of this study was to pilot test the Multimodal Exertional Test (MET) protocol in a sample of healthy interuniversity athletes. Methods: The MET comprises four stages, each featuring three distinct tasks. The test begins with engaging in squats, alternating reverse lunges, and hip hinges (Stage 1). The next stage progressively evolves into executing these tasks within specified time limits (Stage 2). Following this, the test advances to a stage that incorporates cognitive tasks (Stage 3), and the final stage demands greater levels of physical exertion, cognition, and multi-directional movements (Stage 4). Heart rate (HR) was obtained during each stage of the MET and participants' symptom severity scores were recorded following each task. Results: Fourteen healthy interuniversity athletes (n = 8 female, n = 6 male) participated in the study. HR was obtained for 10 of the 14 athletes (females: n = 6, males: n = 4). Increases in average and maximum HR were identified between pre-MET and Stage 1, and between Stages 3 and 4. Consistent with the tasks in each stage, there were no increases in average and maximum HR observed between MET Stages 1 to 3. Female athletes exhibited higher average and maximum HRs compared to male athletes during all four stages. All 14 athletes reported minimal changes in symptom severity following each task. Conclusion: Among healthy athletes, the MET elicits an increase in average and maximum HR throughout the protocol without symptom provocation. Female athletes exhibit higher HRs during all four stages in comparison to male athletes.

Smartphone App-Delivered Mindfulness-Based Intervention for Mild Traumatic Brain Injury in Adolescents: Protocol for a Feasibility Randomized Controlled Trial.

BACKGROUND: Concussion in children and adolescents is a significant public health concern, with 30% to 35% of patients at risk for prolonged emotional, cognitive, sleep, or physical symptoms. These symptoms negatively impact a child's quality of life while interfering with their participation in important neurodevelopmental activities such as schoolwork, socializing, and sports. Early psychological intervention following a concussion may improve the ability to regulate emotions and adapt to postinjury symptoms, resulting in the greater acceptance of change; reduced stress; and recovery of somatic, emotional, and cognitive symptoms. OBJECTIVE: The primary objective of this study is to assess the feasibility of conducting a parallel-group (1:1) randomized controlled trial (RCT) to evaluate a digital therapeutics (DTx) mindfulness-based intervention (MBI) in adolescents aged 12 to <18 years. The attention-matched comparator intervention (a math game also used in previous RCTs) will be delivered on the same DTx platform. Both groups will be provided with the standard of care guidelines. The secondary objective is to examine intervention trends for quality of life; resilience; self-efficacy; cognition such as attention, working memory, and executive functioning; symptom burden; and anxiety and depression scores at 4 weeks after concussion, which will inform a more definitive RCT. A subsample will be used to examine whether those randomized to the experimental intervention group have different brain-based imaging patterns compared with those randomized to the control group. METHODS: This study is a double-blind Health Canada-regulated trial. A total of 70 participants will be enrolled within 7 days of concussion and randomly assigned to receive the 4-week DTx MBI (experimental group) or comparator intervention. Feasibility will be assessed based on the recruitment rate, treatment adherence to both interventions, and retention. All outcome measures will be evaluated before the intervention (within 7 days after injury) and at 1, 2, and 4 weeks after the injury. A subset of 60 participants will undergo magnetic resonance imaging within 72 hours and at 4 weeks after recruitment to identify the neurophysiological mechanisms underlying the potential benefits from MBI training in adolescents following a concussion. RESULTS: The recruitment began in October 2022, and the data collection is expected to be completed by September 2024. Data collection and management is still in progress; therefore, data analysis is yet to be conducted. CONCLUSIONS: This trial will confirm the feasibility and resolve uncertainties to inform a future definitive multicenter efficacy RCT. If proven effective, a smartphone-based MBI has the potential to be an accessible and low-risk preventive treatment for youth at risk of experiencing prolonged postconcussion symptoms and complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT05105802; https://classic.clinicaltrials.gov/ct2/show/NCT05105802. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57226.

Optimal Volume of Moderate-to-Vigorous Physical Activity Postconcussion in Children and Adolescents.

Importance: Determining the optimal volume of early moderate-to-vigorous-intensity physical activity (MVPA) after concussion and its association with subsequent symptom burden is important for early postinjury management recommendations. Objectives: To investigate the association between cumulative MVPA (cMVPA) over 2 weeks and subsequent symptom burden at 1 week, 2 weeks, and 4 weeks postinjury in children and examine the association between cMVPA and odds of persisting symptoms after concussion (PSAC) at 2 weeks and 4 weeks postinjury. Design, Setting, and Participants: This multicenter cohort study used data from a randomized clinical trial that was conducted from March 2017 to December 2019 at 3 Canadian pediatric emergency departments in participants aged 10.00 to 17.99 years with acute concussion of less than 48 hours. Data were analyzed from July 2022 to December 2023. Exposure: cMVPA postinjury was measured with accelerometers worn on the waist for 24 hours per day for 13 days postinjury, with measurements deemed valid if participants had 4 or more days of accelerometer data and 3 or fewer consecutive days of missing data. cMVPA at 1 week and 2 weeks postinjury was defined as cMVPA for 7 days and 13 days postinjury, respectively. Multiple imputations were carried out on missing MVPA days. Main Outcomes and measures: Self-reported postconcussion symptom burden at 1 week, 2 weeks, and 4 weeks postinjury using the Health and Behavior Inventory (HBI). PSAC was defined as reliable change on the HBI. A linear mixed-effect model was used for symptom burden at 1 week, 2 weeks, and 4 weeks postinjury with a time × cMVPA interaction. Logistic regressions assessed the association between cMVPA and PSAC. All models were adjusted for prognostically important variables. Results: In this study, 267 of 456 children (119 [44.6%] female; median [IQR] age, 12.9 [11.5 to 14.4] years) were included in the analysis. Participants with greater cMVPA had significantly lower HBI scores at 1 week (75th percentile [258.5 minutes] vs 25th percentile [90.0 minutes]; difference, -5.45 [95% CI, -7.67 to -3.24]) and 2 weeks postinjury (75th percentile [565.0 minutes] vs 25th percentile [237.0 minutes]; difference, -2.85 [95% CI, -4.74 to -0.97]) but not at 4 weeks postinjury (75th percentile [565.0 minutes] vs 25th percentile [237.0 minutes]; difference, -1.24 [95% CI, -3.13 to 0.64]) (P = .20). Symptom burden was not lower beyond the 75th percentile for cMVPA at 1 week or 2 weeks postinjury (1 week, 259 minutes; 2 weeks, 565 minutes) of cMVPA. The odds ratio for the association between 75th and 25th percentile of cMVPA and PSAC was 0.48 (95% CI, 0.24 to 0.94) at 2 weeks. Conclusions and Relevance: In children and adolescents with acute concussion, 259 minutes of cMVPA during the first week postinjury and 565 minutes of cMVPA during the second week postinjury were associated with lower symptom burden at 1 week and 2 weeks postinjury. At 2 weeks postinjury, higher cMVPA volume was associated with 48% reduced odds of PSAC compared with lower cMVPA volume.

Describing High School Stakeholders' Preferences for a Return-to-School Framework Following Concussion.

BACKGROUND: Return to school supports are recommended to facilitate adolescents' re-entry to school following a concussion. However, little is known as to what school stakeholders prefer for a return-to-school process. This study sought to describe the preferences of high school students, parents, and educators for a Return-to-School Framework for adolescents following a concussion. METHODS: We conducted qualitative semi-structured, 1-on-1 or group interviews with high school students (n = 6), parents (n = 5), and educators (n = 15) from Calgary, Canada. Interviews aimed to describe participants' preferences for a Return-to-School Framework for students following a concussion. Interviews were analyzed using conventional content analysis. RESULTS: We organized the data into 4 main themes: (1) purpose of the Return-to-School Framework; (2) format and operation of the Return-to-School Framework; (3) communication about a student's concussion; and (4) necessity of concussion education for students and educators. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: A Return-to-School Framework following concussion should be developed in consultation with families, educators, and students and supports should be tailored to each student. CONCLUSIONS: Participants preferred a standardized and consistent Return-to-School Framework including ongoing communication between stakeholders as well as feasible and individualized school supports.

Longitudinal Brain Perfusion and Symptom Presentation Following Pediatric Concussion: A Pediatric Concussion Assessment of Rest and Exertion+MRI (PedCARE+MRI) Substudy.

Emerging evidence suggests that advanced neuroimaging modalities such as arterial spin labelling (ASL) might have prognostic utility for pediatric concussion. This study aimed to: 1) examine group differences in global and regional brain perfusion in youth with concussion or orthopedic injury (OI) at 72 h and 4 weeks post-injury; 2) examine patterns of abnormal brain perfusion within both groups and their recovery; 3) investigate the association between perfusion and symptom burden within concussed and OI youths at both time-points; and 4) explore perfusion between symptomatic and asymptomatic concussed and OI youths. Youths ages 10.00-17.99 years presenting to the emergency department with an acute concussion or OI were enrolled. ASL-magnetic resonance imaging scans were conducted at 72 h and 4 weeks post-injury to measure brain perfusion, along with completion of the Health Behavior Inventory (HBI) to measure symptoms. Abnormal perfusion clusters were identified using voxel-based z-score analysis at each visit. First, mixed analyses of covariance (ANCOVAs) investigated the Group*Time interaction on global and regional perfusion. Post hoc region of interest (ROI) analyses were performed on significant regions. Second, within-group generalized estimating equations investigated the recovery of abnormal perfusion at an individual level. Third, multiple regressions at each time-point examined the association between HBI and regional perfusion, and between HBI and abnormal perfusion volumes within the concussion group. Fourth, whole-brain one-way ANCOVAs explored differences in regional and abnormal perfusion based on symptomatic status (symptomatic vs. asymptomatic) and OIs at each time-point. A total of 70 youths with a concussion [median age (interquartile range; IQR) = 12.70 (11.67-14.35), 47.1% female] and 29 with an OI [median age (IQR) = 12.05 (11.18-13.89), 41.4% female] were included. Although no Group effect was found in global perfusion, the concussion group showed greater adjusted perfusion within the anterior cingulate cortex/middle frontal gyrus (MFG) and right MFG compared with the OI group across time-points (ps ≤ 0.004). The concussion group showed lower perfusion within the right superior temporal gyrus at both time-points and bilateral occipital gyrus at 4 weeks, (ps ≤ 0.006). The number of hypoperfused clusters was increased at 72 h compared with 4 weeks in the concussion youths (p < 0.001), but not in the OIs. Moreover, Group moderated the HBI-perfusion association within the left precuneus and superior frontal gyrus at both time-points, (ps ≤ 0.001). No association was found between HBI and abnormal perfusion volume within the concussion group at any visits. At 4 weeks, the symptomatic sub-group (n = 10) showed lower adjusted perfusion within the right cerebellum and lingual gyrus, while the asymptomatic sub-group (n = 59) showed lower adjusted perfusion within the left calcarine, but greater perfusion within the left medial orbitofrontal cortex, right middle frontal gyrus, and bilateral caudate compared with OIs. Yet, no group differences were observed in the number of abnormal perfusion clusters or volumes at any visit. The present study suggests that symptoms may be associated with changes in regional perfusion, but not abnormal perfusion levels.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Youth intentions to provide social support to a peer with a concussion.

OBJECTIVES: 1) To describe demographic factors, concussion knowledge, attitudes, subjective norms, self-efficacy and intentions to provide social support to a peer with a concussion and 2) to examine if demographic factors and concussion knowledge are associated with components of the Theory of Planned Behavior. METHODS: The survey was completed between October 2018 and February 2019 by 200 youth (M = 15.30 years, SD = 1.52). Questions were designed for athletes and non-athletes and inquired about various types of social support. Data analysis included descriptive statistics, Wilcoxon Rank Sum Tests and Spearman's Rank-Order Correlation Coefficients. RESULTS: More favorable attitudes and intentions to provide social support were observed among females (W = 2576, p ≤ 0.001; W = 2411, p ≤ 0.001), older youth (rho = 0.32, p ≤ 0.001; rho = 0.41, p ≤ 0.001) and those with higher concussion knowledge (rho = 0.29, p ≤ 0.001; rho = 0.22; p ≤ 0.001). Participating in sports with a high-risk of concussion was associated with lower attitudes and intentions to provide social support (W = 6677; p ≤ 0.001; W = 6721; p ≤ 0.001). Self-reported concussion history or knowing someone with a concussion history was not significantly associated with social support intentions. CONCLUSION: This study identified characteristics of youth who had positive intentions to provide social support. These findings identify individuals who may model providing social support to a peer, as well as opportunities for future concussion education.

Unravelling the web: Experiences of adolescents returning to school following a concussion.

One in five adolescents will sustain a concussion in their lifetime. A concussion may result in symptoms that affect an adolescent's ability to attend school and engage in learning tasks. This study was guided by interpretivism. We conducted one-on-one semi-structured interviews to explore the perspectives of 20 adolescents (ages 14-18) returning to school after a concussion. Interviews were coded inductively and analyzed using reflexive thematic analysis. Five interconnected themes emerged with returning to school and accessing school supports: (1) concussion symptoms affected adolescents' schoolwork; (2) access to academic accommodations eased adolescents' return to school; (3) having supportive and understanding friends, family, and teachers facilitated adolescents' return to school; (4) communication amongst school stakeholders was desired, but often lacking; and (5) feeling anxious, frustrated, and sad with the return to school process. Adolescents' experiences were multifaceted and many factors contributed to their return to school experiences. Our findings can inform our understanding of the experiences of adolescents returning to school following concussion and can inform the development of concussion management supports at schools.

NET-02: a randomised, non-comparative, phase II trial of nal-IRI/5-FU or docetaxel as second-line therapy in patients with progressive poorly differentiated extra-pulmonary neuroendocrine carcinoma.

Background: The prognosis for patients with poorly-differentiated extra-pulmonary neuroendocrine carcinoma (PD-EP-NEC) is poor. A recognised first-line (1L) treatment for advanced disease is etoposide/platinum-based chemotherapy with no standard second-line (2L) treatment. Methods: Patients with histologically-confirmed PD-EP-NEC (Ki-67 > 20%; Grade 3) received IV liposomal irinotecan (nal-IRI) (70 mg/m2 free base)/5-FU (2400 mg/m2)/folinic acid, Q14 days (ARM A), or IV docetaxel (75 mg/m2), Q21 days (ARM B), as 2L therapy. Primary endpoint was 6-month progression-free survival (PFS) rate (80% power to demonstrate one-sided 95% lower confidence interval excluded 15% (target level of efficacy: 30%)). Secondary endpoints: objective response rate (ORR), median PFS, overall survival (OS), toxicity and patient-reported quality-of-life (QoL) (ClinicalTrials.gov: NCT03837977). Findings: Of 58 patients (29 each arm); 57% male, 90% ECOG PS 0/1, 10% PS 2, 89.7% Ki-67 ≥ 55%, primary site: 70.7%-gastrointestinal, 18.9%-other, 10.3%-unknown, 91.4%/6.9%/1.7% were resistant/sensitive/intolerant to 1L platinum-based treatment, respectively. The primary end-point of 6-month PFS rate was met by ARM A: 29.6% (lower 95% Confidence-Limit (CL) 15.7), but not by ARM B: 13.8% (lower 95%CL:4.9). ORR, median PFS and OS were 11.1% (95%CI:2.4-29.2) and 10.3% (95%CI:2.2-27.4%); 3 months (95%CI:2-6) and 2 months (95%CI:2-2); and 6 months (95%CI:3-10) and 6 months (95%CI:3-9) in ARMS A and B, respectively. Adverse events ≥ grade 3 occurred in 51.7% and 55.2% (1 and 6 discontinuations due to toxicity in ARMS A and B), respectively. QoL was maintained in ARM A, but not ARM B. Interpretation: nal-IRI/5-FU/folinic acid, but not docetaxel, met the primary endpoint, with manageable toxicity and maintained QoL, with no difference in OS. ORR and median PFS were similar in both arms. This study provides prospective efficacy, toxicity and QoL data in the 2L setting in a disease group of unmet need, and represents some of the strongest evidence available to recommend systemic treatment to these patients. Funding: Servier.

Partnering With Patients, Caregivers, and Clinicians to Determine Research Priorities for Concussion.

Importance: Identifying research priorities of patients with concussion, their caregivers, and their clinicians is important to ensure future concussion research reflects the needs of those who will benefit from the research. Objective: To prioritize concussion research questions from the perspectives of patients, caregivers, and clinicians. Design, Setting, and Participants: This cross-sectional survey study used the standardized James Lind Alliance priority-setting partnership methods (2 online cross-sectional surveys and 1 virtual consensus workshop using modified Delphi and nominal group techniques). Data were collected between October 1, 2020, and May 26, 2022, from people with lived concussion experience (patients and caregivers) and clinicians who treat concussion throughout Canada. Exposures: The first survey collected unanswered questions about concussion that were compiled into summary questions and checked against research evidence to ensure they were unanswered. A second priority-setting survey generated a short list of questions, and 24 participants attended a final priority-setting workshop to decide on the top 10 research questions. Main Outcomes and Measures: Top 10 concussion research questions. Results: The first survey had 249 respondents (159 [64%] who identified as female; mean [SD] age, 45.1 [16.3] years), including 145 with lived experience and 104 clinicians. A total of 1761 concussion research questions and comments were collected and 1515 (86%) were considered in scope. These were combined into 88 summary questions, of which 5 were considered answered following evidence review, 14 were further combined to form new summary questions, and 10 were removed for being submitted by only 1 or 2 respondents. The 59 unanswered questions were circulated in a second survey, which had 989 respondents (764 [77%] who identified as female; mean [SD] age, 43.0 [4.2] years), including 654 people who identified as having lived experience and 327 who identified as clinicians (excluding 8 who did not record type of participant). This resulted in 17 questions short-listed for the final workshop. The top 10 concussion research questions were decided by consensus at the workshop. The main research question themes focused on early and accurate concussion diagnosis, effective symptom management, and prediction of poor outcomes. Conclusions and Relevance: This priority-setting partnership identified the top 10 patient-oriented research questions in concussion. These questions can be used to provide direction to the concussion research community and help prioritize funding for research that matters most to patients living with concussion and those who care for them.

Academic Accommodations for Middle and High School Students Following a Concussion: Perspectives of Teachers and School Administrators.

BACKGROUND: An estimated 1 in 5 adolescents have sustained a concussion in North America. Teachers and school administrators are responsible for implementing academic accommodations and other supports for optimal return to learn following a concussion. The primary objective of this study was to describe the prevalence and feasibility of providing academic accommodations to students following concussion from the perspectives of middle and high school teachers and school administrators. METHODS: A cross-sectional survey was administered to teachers and school administrators (grades 7-12) across Canada online via REDCap. Participants were recruited via word-of-mouth and social media sampling. Survey responses were analyzed descriptively using proportions. RESULTS: The survey was completed by 180 educators (138 teachers and 41 school administrators), of whom 86% had previously provided academic accommodations to students following concussion, and 96% agreed that students should have access to accommodations following concussion. Some accommodations (eg, breaks, extra time) were provided more often and were more feasible to provide than others (eg, no new learning, reduced bright light). Educators reported limited preparation time and limited school personnel support to assist students following concussion. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: The most feasible accommodations should be prioritized, ensuring students are supported within the school environment. CONCLUSIONS: Teachers and school administrators confirmed the importance of providing accommodations to students following concussion.

Delivering concussion education to pre-service teachers through the SCHOOLFirst website: Evaluating usability and satisfaction.

BACKGROUND: Return-to-school processes indicate 'when' to initiate activities and 'what' activities should be accomplished, but are missing 'how' to implement the process. The SCHOOLFirst website provides the 'how' through building concussion knowledge, creating a supportive culture, and defining roles. Due to the involvement of pre-service teachers in schools during training and imminent transition to becoming teachers, it is important that pre-service teachers are trained in concussion and can optimally support current and future students. OBJECTIVE: To determine: 1) pre-service teachers' knowledge and confidence surrounding the return-to-school process before and after using the SCHOOLFirst website; 2) the usability, intended use and satisfaction of the SCHOOLFirst website from the perspective of pre-service teachers. METHODS: Thirty pre-service teachers completed the demographic survey, knowledge and confidence survey, System Usability Scale, and satisfaction and intended use survey after participating in a workshop. RESULTS: Significant increases in concussion knowledge (Z = -4.093, p < 0.001) and confidence in helping students return-to-school (Z = -4.620, p < 0.001) were measured after using the SCHOOLFirst website. Participants were satisfied with the SCHOOLFirst website (93.4%) and intend to use it in the future when supporting a student post-concussion (96.4%). CONCLUSION: The SCHOOLFirst website is a valuable tool for pre-service teachers to support students' return-to-school post-concussion.

The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury.

OBJECTIVE: To develop new diagnostic criteria for mild traumatic brain injury (TBI) that are appropriate for use across the lifespan and in sports, civilian trauma, and military settings. DESIGN: Rapid evidence reviews on 12 clinical questions and Delphi method for expert consensus. PARTICIPANTS: The Mild Traumatic Brain Injury Task Force of the American Congress of Rehabilitation Medicine Brain Injury Special Interest Group convened a Working Group of 17 members and an external interdisciplinary expert panel of 32 clinician-scientists. Public stakeholder feedback was analyzed from 68 individuals and 23 organizations. RESULTS: The first 2 Delphi votes asked the expert panel to rate their agreement with both the diagnostic criteria for mild TBI and the supporting evidence statements. In the first round, 10 of 12 evidence statements reached consensus agreement. Revised evidence statements underwent a second round of expert panel voting, where consensus was achieved for all. For the diagnostic criteria, the final agreement rate, after the third vote, was 90.7%. Public stakeholder feedback was incorporated into the diagnostic criteria revision prior to the third expert panel vote. A terminology question was added to the third round of Delphi voting, where 30 of 32 (93.8%) expert panel members agreed that 'the diagnostic label 'concussion' may be used interchangeably with 'mild TBI' when neuroimaging is normal or not clinically indicated.' CONCLUSIONS: New diagnostic criteria for mild TBI were developed through an evidence review and expert consensus process. Having unified diagnostic criteria for mild TBI can improve the quality and consistency of mild TBI research and clinical care.

Online youth concussion resources for Canadian teachers and school staff: A systematic search strategy.

INTRODUCTION: Teachers and school staff (i.e., principals, coaches, trainers, educational assistants, guidance counselors, school healthcare professionals, etc.) are well positioned to support students' return-to-school post-concussion. Teachers and school staff may access concussion resources online as they are readily available; however, their quality and accuracy are unknown. OBJECTIVE: To identify accurate online concussion resources suitable for Canadian teachers and school staff. METHODS: A five-phased systematic search strategy was conducted: 1) initial identification of resources; 2) consultation of pediatric concussion experts; 3) inclusion and exclusion criteria; 4) content review; and, 5) material evaluation. RESULTS: A total of 837 resources were identified initially and 40 resources were included in the final list. Across all resources, 310 (37%) resources were excluded as they were not designed primarily for teachers and school staff. Thirty-four (43%) of 80 resources reviewed for content accuracy were excluded. Among resources reviewed for readability, usability and suitability, six (13%) were excluded. CONCLUSIONS: The 40 resources identified in this study can enable teachers and school staff to educate themselves about concussion and how to optimally support a student's return-to-school post-concussion.

A Scoping Review of Magnetic Resonance Modalities Used in Detection of Persistent Postconcussion Symptoms in Pediatric Populations.

Up to 30% of youth with concussion experience PPCSs (PPCS) lasting 4 weeks or longer, and can significantly impact quality of life. Magnetic resonance imaging (MRI) has the potential to increase understanding of causal mechanisms underlying PPCS. However, there are no clear modalities to assist in detecting PPCS. This scoping review aims to synthesize findings on utilization of MRI among children and youth with PPCS, and summarize progress and limitations. Thirty-six studies were included from 4907 identified papers. Many studies used multiple modalities, including (1) structural (n = 27) such as T1-weighted imaging, diffusion weighted imaging, and susceptibility weighted imaging; and (2) functional (n = 23) such as functional MRI and perfusion-weighted imaging. Findings were heterogeneous among modalities and regions of interest, which warrants future reviews that report on the patterns and potential advancements in the field. Consideration of modalities that target PPCS prediction and sensitive modalities that can supplement a biopsychosocial approach to PPCS would benefit future research.

Multi-domain assessment of sports-related and military concussion recovery: A scoping review.

OBJECTIVE: This review explores the literature on multi-domain assessments used in concussion recovery, to inform evidence-based and ecologically valid return-to-play. It asks: What simultaneous, dynamic multi-domain paradigms are used to assess recovery of youth and adults following concussion? METHODS: Five databases were searched (CINAHL, EMBASE, MEDLINE, PsycInfo, SPORTDiscus) until September 30, 2021. Records were limited to those published in peer-reviewed journals, in English, between 2002 and 2021. Included studies were required to describe the assessment of concussion recovery using dynamic paradigms (i.e., requiring sport-like coordination) spanning multiple domains (i.e., physical, cognitive, socio-emotional functioning) simultaneously. RESULTS: 7098 unique articles were identified. 64 were included for analysis, describing 36 unique assessments of 1938 concussed participants. These assessments were deconstructed into their constituent tasks: 13 physical, 17 cognitive, and one socio-emotional. Combinations of these "building blocks" formed the multi-domain assessments. Forty-six studies implemented level walking with a concurrent cognitive task. The most frequently implemented cognitive tasks were 'Q&A' paradigms requiring participants to answer questions aloud during a physical task. CONCLUSIONS: A preference emerged for dual-task assessments, specifically combinations of level walking and Q&A tasks. Future research should balance ecological validity and clinical feasibility in multi-domain assessments, and work to validate these assessments for practice.

R2Play development: Fostering user-driven technology that supports return-to-play decision-making following pediatric concussion.

Objective: To design a multi-domain return-to-play assessment system (R2Play) for youth athletes with concussion. Methods: The R2Play system was developed using an overarching user-centered approach, the Design Thinking Framework, and research activities included: 1) structured brainstorming within our research team, 2) interviews with clinician and youth sports coaches, 3) building a testable prototype, and 4) interface testing through cognitive walkthroughs with clinician partners. Results: Clinician and coach participants provided feedback on the R2Play concept, which was integrated into the design process and provided future directions for research. Examples of feedback-driven design choices included reducing assessment time, increasing ecological validity by adding in background noise, and developing youth-friendly graphical results screens. Following refinement based on stakeholder feedback, the R2Play system was outlined in detail and a testable prototype was developed. It is made up of two parts: a clinician tablet, and a series of tablet "buttons" that display numbers and letters. Youth athletes run between the buttons to connect a "trail" in ascending alphanumeric order, 1-A-2-B, etc. Their performance across a series of levels of increasing difficulty is logged on the clinician tablet. Initial testing with five clinicians showed the system's interface to have excellent usability with a score of 81% (SD = 8.02) on the System Usability Scale. Conclusion: Through this research, a prototype of the R2Play system was innovated and evaluated by clinician and coach stakeholders. Initial usability was excellent and directions for future iterations were highlighted. Outcomes suggest the potential benefits of using technologies to assist in complex clinical assessment, as well as utilizing a user-centered approach to design.